Category: Health

Health based on Poverty and its measurement.

Photo by Adam Jang on Unsplash

Health based on Poverty and its measurement.

 

One of the explanatory frameworks, or ‘discourses’, for ill health and health inequalities around access to health services and health outcomes, is that of the ‘material deprivation’ thesis, which underpins much of the Marmot Review Fair Society Healthy Lives. It sits within a ‘Redistribution discourse’, which suggests the answer is redistribution of material resources. Alongside this is the ‘Psychosocial Comparison Thesis’, which underpins such work as Wilkinson and Pickett’s The Spirit Level. This forms part of the ‘Social Integrationist discourse’ in which reduction of social inequalities and better integration of marginalised groups is important.

 

Material deprivation focuses on a lack of resources to support healthy living while psychosocial comparison suggests one’s position in the social hierarchy, and the level of inequality in society, create psychosocial stress harmful to health. They are not mutually exclusive and of course might work together for some individuals resulting in poorer health outcomes for them. Being poor in a very unequal society is thus very harmful to health and results in gross inequalities in health.

 

A third explanatory framework is the ‘cultural thesis’ which suggests it is the culture of certain behaviours, attitudes, values and norms that are the root cause of ill health. Another term for this way of thinking is the ‘moral underclass discourse’. The answer is to make better choices and improve lifestyle activities such as stopping smoking, reducing alcohol consumption, exercising more and eating better. Poor people are disproportionately ill because of their poor life decisions. The ‘underclass’ make poor moral decisions and therefore bring ill health upon themselves. The material deprivation they experience is a result of their own poor life choices, their parents’ life choices, or it results from being ill, preventing them from working or making better life choices (the deserving poor).

 

The Consensual Method of measuring poverty.

 

A link between all three is material deprivation resulting from poverty, but what do we mean by poverty and how is it measured? In the UK we do not use the concept of absolute poverty, instead some reports are using the term ‘relative poverty’, one measure of which is the consensual method. The research project Poverty and Social Exclusion (PSE) outlines what this is. In short this focuses on deprivation as:

 

“enforced lack of necessities determined by public opinion”.

 

In the consensual approach we first need to establish what those items are that make up our ‘standard of living’ and then identify which of those items most people view as ‘necessities’. Consider a mobile phone as an item, if most people think this is a necessity, then not having one begins to identify oneself as poor. The necessities are what most people think everyone should be able to afford and which no one should be without. Poverty is where these deprivations impact on a person’s whole way of life; to measure poverty we need to know how many people there are whose ‘enforced lack of necessities’ affects their way of living. Note that those who choose not to have these necessities would not count.

 

Items that are necessary include the social as well as the material. The PSE have published data on what the public thinks those items are: for example, 96% of us think ‘heating to warm living areas of the home’, 94% think a ‘damp free home’ and 91% think ‘two meals a day for adults’ are some of the necessities. However some items go beyond ‘basic’ needs such as ‘visiting friends/family in hospital’ (90%), and ‘attending a wedding/funeral’ (79%).

 

What do you think everyone should be able to afford?

What do you think no one should be without?

 

Once we have these benchmarks, then we can start to measure the base line below which society considers people to be deprived. This is what is being attempted since 1983 and the ‘Breadline Britain’report.

 

The 2013 PSE first report ‘The impoverishment of the UK’ PSE first results: Living Standards’ indicates the scale and extent of poverty in the UK (the 6th richest country as measured by GDP per capita). One section of the report ‘Going backwards 1983-2012’ suggests that the proportion of households falling below minimum standards has doubled since 1983:

 

1. More children lead impoverished and restricted lives today than in 1999.

2. 5 million more people live in inadequate housing than in the 1990s.

3. 9% of households can’t heat their homes adequately today up from 5% in 1983 and 3% in 1999.

4. 33% of households experience below par living standards.

 

This is despite the fact that the UK is a far richer country now than it was in the 1980’s. The size of the economy has doubled over the last 30 years. This supports the claim that economic and wealth creation has benefitted the better off while families lower down continue to struggle to meet their basic needs.

 

Source: http://www.poverty.ac.uk/pse-research/going-backwards-1983-2012

 

If you emphasise that ill health and deprivation results from poor life choices, then you might not be interested that more and more families are experiencing deprivation of this kind. It is a case of them not taking up opportunities, not working hard at their education or not moving to where employment is higher, i.e. London and the South East. However, you might want to wonder why more and more families are making these poor life choices since the 1980’s, especially if during that time knowledge about what is the basis for a healthy life, is more easily accessible with the internet.

 

Or you might think that regardless of the fact that more people falling into this category, this does not mean that they are also more likely to experience health inequalities such as reductions in life expectancy. The data from such sources as the Community Health Profiles and that contained in ‘Fair Society, Healthy Lives’ and ‘The Spirit Level’ would suggest otherwise.

 

 

 

Source: http://www.poverty.ac.uk/pse-research/going-backwards-1983-2012

 

 

watch this video for a first hand account.

 

 

What are the implications of this knowledge for nurses? Is this a ‘social issue’ irrelevant to nursing practice?

 

 

The Violence of Austerity 2

Rudolph Virchow (1848) argued that ‘medicine is a social science and politics is nothing more than medicine on a grand scale’.

Structural and Institutional violence arises from the implementation of Austerity. Cameron, Osborne, May and Hammond have blood on their hands. Johnson, Gove, Rudd, Grayling…….

In 2013 David Stuckler and Sanjay Basu published ‘The Body Economic – Why Austerity Kills’ and stated that since 2007 the total number of suicides had risen by 10000 across the US and Europe while millions lost access to basic healthcare. Chopra (2014) reviews the book and points out that ‘Mental health outcomes feature prominently in these analyses. For instance, the authors report 1000 excess suicides in the UK due to the effects of this recession and a second wave of ‘austerity suicides’ in 2012‘.

 

Following the Great Financial Crash (GFC) of 2008, the neoliberal project in the UK was given an opportunity to push further on its (class) agenda which had been based on reducing State support for the public sector and social security claimants, encouraging privatisations, establishing financial deregulation, reduction of corporate tax and removing ‘red tape’ (worker’s rights and enviromental protection). The theory was based on ‘trickle down economics’ and Hayekian ‘free markets’. Jobs, growth and investment would follow. Austerity in this context was seen as a necessary corrective to the failing economy. It was not mentioned of course that one reason for the GFC was neoliberalism itself. In effect we have a neoliberal policy being implemented to correct the failures of neoliberalism.

For the sake of argument, lets accept the claim that indeed the UK enjoyed pre crash levels of growth above OECD averages (it has not), produced a high number of well paid secure, high skilled jobs with wage growth (it did not), and that investment significantly rose (it has not) and that productivity has soared (it has not). What is Austerity and what are its founding myths?

If a major tenet of neoliberalism is a reduction in state withdrawal from services and from support for workers and claimants, Austerity turbo charges it in the name of deficit reduction to address the national debt.

Austerity is first and foremost a move to permanently dissemble the protection state (Cooper and Whyte 2017) through reductions in targetted public spending. The view is taken that skivers and shirkers have grown fat on the largesse of the British Welfare State, a State that breeds dependency and since the GFC it is argued is now unaffordable. It is not about reducing state spending per se, as subsidies to the nuclear industry and help to buy schemes attest. Indeed State spending as a % share of GDP has not really moved since 2010. It is this that makes the ‘reduction of state spending’ neoliberalism rhetoric (as ideologically based class war) but not reality for the rich.

 

Austerity is based on the idea of ‘expansionary fiscal consolidation‘ (Alesina and Perotti 1995). Government cuts to public spending will (the theory says) encourage more private consumption and business investment. Not cutting public spending jeopardises investment and competitiveness. The reality is that public consumption in the UK is debt fuelled rather than from higher wages, and investment remains very poor.

Three myths underpin this approach from 2010:

  1. We all played a part in the financial crisis (New Labour caused the crash).
  2. Austerity is necessary.
  3. We are all in this together.

However, this masks real reasons for the policy:

  1. To further ease Capital Accumulation for the rich.
  2. To further extend wealth by growing inequality and through dispossession.
  3. To permanently dissemble the protectionist State.

In short: the violence of class war. Capital v Labour, the irreducible foundational contradiction of capitalism.

The institutional violence meted out by for example by G4S and ATOS is ‘ordinary’ mundane process violence, it is not exceptional but routine as experienced in people’s lives, involving fear humiliation, hunger, shame and early deaths. Using ‘maladaptive coping’ such as eating high fat sugary food, smoking, excessive drinking, taking drugs and having unprotected promiscuous sex, are as much reactions to as causes of poverty and violence. This ‘Moral Underclass Discourse’, which points to poor individual lifestyle choices, ignores the wider determinants of health, the mass of data on the ‘social gradient’ in health and of health inequalities. It also does not understand the complexity of personal agency and social structure in which reflexive deliberations (our inner voices) mediate between objective social structures, cultures and our personal concerns and projects.

We make our own history, but not in the circumstances of our own choosing“.

Institutional violence is pervasive and normalised so that we don’t always see it or feel it for what it is. Food banks, deportations, homelessness, debt, trafficking, evictions, precarity in low wage jobs are becoming part of the social fabric that is getting thinner by the day. This violence is slow violence whose effects may take time to come through. It also provides a pervasive threat of violence for those lacking the financial, social, cultural capital to either protect themselves or to escape.

Richard Horton (2017) in the Lancet (note not ‘Marxism Today’) outlined the arguments well:

Economists are the gods of global health. Their dazzling cloak of quantitative authority and their monstrously broad range of inquiry silence the smaller voices of medicine, trapped as we are in the modest discipline of biology. Economists stepped beyond the boundaries of the body long ago. They now bestride the predicaments of our planet with confident insouciance. It is economists we must thank for the modern epidemic of austerity that has engulfed our world. Austerity is the calling card of neoliberalism. Its effects follow an inverse harm law—the impact of increasing amounts of austerity varies inversely with the ability of communities to protect themselves. Austerity is an instrument of malice. Search under austerity and you will find few countries unaffected. Greece, of course, but also Mozambique, France, Scotland, Brazil, Portugal, Spain, Cameroon, Belgium, the Netherlands, South Africa, and England. Economists advocating, and governments implementing, austerity naturally reject the word. Instead, they call austerity, “living within our means”. But be clear. What is promoted as fiscal discipline is a political choice. A political choice that deepens the already open and bloody wounds of the poor and precarious. The Financial Times, a newspaper usually in thrall to the spectacle of economics, called these policies “inhumane” last weekend.

But austerity is also a social contract. People accept severe restraints in public spending, actively in democracies or passively in autocracies, because they accept the unpalatable prescription of abstinence. Yet the public too has a choice. And they are exercising that choice in countries across the globe. Take the UK. Back in 1991, two-thirds of the British population wanted more taxation and spending. But by 2006, only a third of people backed redistribution of wealth. If not welcomed, austerity was accepted. Not now. In the latest British Social Attitudes Survey, published last week, public opinion had turned against the idea of brutal scarcity. 48% of people wanted taxation increased to enable greater investments in society. 42% supported redistribution of income. And health was their priority—83% of people wanted more spending on our collective wellbeing. After a decade of cutting back the reach of government, the public is now demanding a stronger and more generous state. The contract authorising austerity has been torn up“.

Richard seems to be suggesting we may be at a turning point. I hope he is right, but with a Brexit fixated government backed by 30% of those eligible to vote (the 52%) and the cheerleaders in the right wing press driving politics onwards, I don’t yet see much hope.

The Violence of Austerity

Photo by Samuel Zeller on Unsplash

This is based on the recent 2017 book by Vickie Cooper and David Whyte.

When society places hundreds of proletarians in such a position that they inevitably meet a too early and an unnatural death, one which is quite as much a death by violence as that by the sword or bullet, its deed is murder just as surely as the deed of the single individual.” Engels (1845) ‘The Condition of the Working Class in England’.

Let us be clear from the outset. This is not about interpersonal violence carried out by one person directly on another using physical or emotional force. This is about Institutional violence, carried out by smartly dressed ordinary men and women in offices up and down the country, who often are merely following orders or who were architects of the policies that kill or cause physical and psychological harm. The malefactors of great wealth stand behind the lines cheering them on, using their propaganda news media to convince the victims that the victims are to blame. The malefactors of great wealth also grow fat on the proceeds of the sales of products designed to dull the senses and anaesthetise the pain caused by institutional or structural violence – high fat, sugar loaded fast foods, cigarettes, alcohol, cheap TV and mass culture in a dystopian miasma of false dreams.

Some may doubt the existence of institutional violence, perhaps arguing that only human beings can directly inflict pain. Johan Galtung (1969) in ‘Violence, Peace and Peace Research’ wrote of structural violence; a violence in which some social structure or social institution causes harm by preventing people from meeting basic needs. This is a model of violence that goes beyond notions that focus only on individual agency. Gregg Barak (2003) in ‘Violence and Nonviolence: pathways to understanding’ argues:

Like interpersonal forms of violence, institutional forms include physically or emotionally abusive acts. However, institutional forms of violence are usually, but not always, impersonal: that is to say, almost any person from the designated group of victims will do.

Yes. “any person” from the sea of faceless ‘skivers, shirkers, unemployed, disabled, sick, mentally ill, low paid and feckless’ who have been systematically stripped of their personhood by bureaucratic processes designed to make their lives hell in order to ‘incentivise’ them to find work.

Barak goes on: “Moreover, abuses or assaults that are practiced by corporate bodies—groups, organizations, or even a single individual on behalf of others—include those forms of violence that over time have become “institutionalized,” such as war, racism, sexism, terrorism, and so on. These forms of violence may be expressed directly against particular victims by individuals and groups or indirectly against entire groups of people by capricious policies and procedures carried out by people “doing their jobs,” differentiated only by a myriad of rationales

People “doing their jobs” using thoughtlessness, banality and cliché to justify their actions or perhaps in fear of joining the ranks of the precariat themselves. The current most important banality and cliché currently in force is ‘Austerity’ and its attendant lies used as justification.

Galtung: “violence is present when human beings are being influenced so that their actual somatic and mental realizations are below their potential realizations”

  1. Violence is a phenomenon which reduces a person’s potential for performance. A distinction must be made between violence and force, since the former breeds negative results, while this is not necessarily so in the case of the latter. This is an important option, because many people consider that violence may have both positive and negative results.
  2. Violence should be objectively measured according to its results, not in a subjective manner. Suicide, mental illness, mortality and morbidity rates, hunger, and poverty.

Felipe, MacGregor and Marcial Rubio refer back to Galtung and provide their own definition of violence:

A physical, biological or spiritual pressure, directly or indirectly exercised by a person on someone else, which, when exceeding a certain threshold, reduces or annuls that person’s potential for performance, both at an individual and group level, in the society in which this takes place”.

Criticism of structural or institutional violence, and the denial thereof, may focus on the need for an actor; an actor who can then be held liable for such action. Personal or direct violence is a violence in which an aggressor can be identified, face to face, whereby the victim can recognise a guilty person through direct confrontation. This is far too narrow a definition with perhaps the paradigm case for institutional violence being Adolf Eichmann who never actually got his hands dirty.

If these definitions hold, current government ministers, civil servants, local authority bureaucrats are complicit in the violence inflicted upon claimants for universal credit, those who died undergoing work capability assessments and those who died in Grenfell Tower.

It is the contention of Cooper and Whyte, along with Stuckler and Basu, that ‘Austerity kills’.

The Sociological Imagination

“The sociological imagination enables us to grasp history and biography and the relations between the two within society. That is its task and its promise” C. Wright Mills

Photo by Lance Anderson on Unsplash

This is a key work in the sociological literature and provides a way of thinking about our experiences as individuals in society at any given point in time. The argument is that to fully understand ourselves we have to apply the ‘sociological imagination’ to our ‘personal troubles’.

The relevance for health is that this takes us beyond making overly simplistic analysis of our health behaviours, experiences and decisions. If our analysis is too simplistic then we come up partial answers to health care issues at best and irrelevant, judgemental or dangerous answers at worst.

C Wright Mills wrote:

‘…men (sic) do not usually define the troubles they endure in terms of historical change…’ (p3).

So, what is a ‘trouble’?  That might be an episode of illness.

 

 

Personal troubles:

 

  • Having type 2 diabetes and thus having to manage that condition
  • Living alone
  • Being overweight
  • Worries about changes in the benefits system

 

 

We may not consider that our issues (as personal troubles) are better or more fully understood as being linked to living in the 21st century, or that the roots may lie in current society. We are

‘…seldom aware of the intricate connection between the patterns of their own lives and the course of world history.’ (p4).

We do not

‘…possess the quality of mind essential to grasp the interplay of man and society, of biography and history…’  (p4).

In addition we:

‘…cannot cope with their personal troubles in such ways as to control the structural transformations that lie behind them.’  (p4).

What ‘structural transformations’ might be behind living alone, diabetes, weight gain and money worries?

What is a ‘structural transformation?’

If we think of society has having ‘structures’, which vary from society to society and which varies within the same society over time (history), we may begin to understand that society is but the outcome of individuals, groups, communities and populations deciding to act out their relationships one with another. In doing so they create (and are created by) society and its social ‘structures’. We have family structures, gender role structures, work organisation and employment structures, educational structures, health care delivery structures, food manufacture, marketing and delivery structures, economic structures…..  A commonly experienced social structure today is the baking or buying and eating of cake and coffee as a social event. In response to, or perhaps to encourage this, we now have both small businesses in town centres and global corporations (Nestle, Starbucks, Costa Coffee) oriented to selling us high calorie non essential  food and drink.

Relationships between people evolve as humans live their lives and develop their capacities and these relationships then act as structural patterns for others to follow. This process of ‘evolution’ and ‘pattern’ changes over time and between societies. An individual thus is both shaped by these (structural) patterns of living, and in living their lives they in turn shape the patterns (structures). Our lives are thus ‘structured’ but not determined by these structures.

What social structures are there and what are those structures that lie beneath the personal troubles outlined above?

To help answer that question Wright Mills argued that

 

what they need…is a quality of mind that will help them to use information and to develop reason in order to achieve lucid summations of what is going on in the world and of what may be happening within themselves… this quality…(is) the sociological imagination.” (p5).

 

What information do we have about Type 2 diabetes – its rate, prevalence, risk groups, epidemiology, aetiology, and the wider determinants? To fully understand why anyone now has Type 2 we need to get this information and consider for example that:

 

We might be ‘overweight’. What exactly does that mean and how much of an issue is it? The fact that we might now have type 2 diabetes suggests that previous diet, levels of exercise and lifestyle may have contributed. What do we know about weight gain and the link to diabetes?

Our personal story of being overweight is linked to various structural and technological changes in society over our lifetime. These changes include the abundance of fossil fuels to use for energy (a technological change) instead of food, so that cars replace cycling/walking. Active travel is replaced by driving, while the social meaning of driving and car ownership underpin our unwillingness to cycle, walk to the bus stop or railway station.

So, to what degree are we responsible for gaining this weight? Many of us have lived through a time when the public’s understanding of diet was perhaps rudimentary, constrained as it was by rationing and availability and the social norms that construct a ‘healthy’ diet. Many of us experienced ‘socialisation’ which involves learning the values, norms and beliefs of our culture regarding what is appropriate food. To what degree is  vegetarianism, veganism or the mediterranean diet, popular and or promoted as healthy option?

We need to consider what a healthy diet is and how the public get to know. Currently the eatwell plate is a suggestion, but to what degree do the public know about it, how much are they guided by it and what is the evidence base for it? We might want to consider if there are any vested interests in selling us high calorie, sugar dense foodstuffs?

Exercising a sociological imagination also asks what social changes occurred so that we have now an abundance of sugar in the form of high fructose corn syrup?

Our early lives would have been guided by social norms and what shops could provide, as well as cost. the ‘personal trouble’ is weight gain but it is also a public issue as the whole UK population has gained weight. So we need to connect changes in social structures and historical events to the personal story that is a diagnosis of diabetes, to fully understand current health.

The role of sugar in the diet is an issue, what is the history of the dietary advice regarding fat and sugar? We may well have been consuming sugar in amounts that seems normal and indeed is hidden. This could be part of what is called an ‘obesogenic environment’ in which we are immersed and have been for several decades. What do we believe and think about sugar in the diet? To what degree does rational thinking about the risk to weight from eating a ‘normal’ UK diet, feature in buying, cooking and meal preparation decisions?

 

The sociological imagination enables its possessor to understand the larger historical scene in terms of its meaning for the inner life….’ (p5).

This is what Wright Mills refers to when he argued that:

The first fruit of this imagination…is the idea that the individual can understand his own experience and gauge his own fate only by locating himself within his period, that he can know his own chances in life only by becoming aware of all those individuals in his circumstances’ (p5).

 

Wright Mills outlines:

‘The personal troubles of milieu and the public issues of social structure’. (p8).

Troubles:

These occur within the individual’s immediate experience and relationships. They relate to the individual self and to those areas of social life of which the individual is immediately, directly and personally aware. The description of what the trouble is and what the solutions are, come from the individual and within the scope of their ‘social milieu’. A trouble is a private matter; they are values that we feel are threatened.

One of our personal troubles may be feeling and living alone and feeling that whatever we does makes no difference (learned helplessness). The value being threatened here is the value of social relationships being missed.

 

 

Learned helplessness is a state of mind which results in the inability or the unwillingness to avoid negative experiences as a result of thinking that those experiences are unavoidable (even if they are avoidable). This arises because one has learned that one does not have control over the situation. Learned helplessness theory is the view that clinical depression and related mental illnesses may result from a perceived absence of control over the outcome of a situation.

 

Public Issues:   

These are matters that go beyond the local environment of the individual and their inner life. They result as an ‘organisation’ of many such situations into the structure and institutions of society. The countless individual social milieux (i.e. ‘all the lonely people’ in the UK) overlap and create society at points in history. An issue is a public matter; issues threaten values held by the public. When this happens there may be public debate about what that value is and what really threatens it. There is some evidence that loneliness is becoming a public issue as the scale of the issue becomes clearer and its health effects become known.

One of Wright Mill’s examples to explain the use of the sociological imagination is unemployment:

‘When…only one man is unemployed, that is his personal trouble, and for its relief we look to the character of the man, his skills and his immediate opportunities. When…15 million…are unemployed, that is an issue, and we may not hope to find the solution within the range of opportunities open to any one individual. The very structure of opportunities has collapsed. Both the correct statement of the problem and the range of possible solutions require us to consider the economic and political institutions of society and not merely the personal situation and character of a scatter of individuals’. (p9).

What the individual unemployed man (out of the 15 million) experiences is often caused by the structural changes in society. When global economics means that steel can be produced more cheaply in a foreign country (a structural change) then a UK steel works shuts down. To be aware of the idea of social structure and to use it, is to be able to trace links among a great variety of individual social milieu which, as Wright Mills’ states, ‘…is to possess the sociological imagination’ (p11).

There is more than one person who lives alone, is overweight, struggling with diabetes and has money worries. Therefore these personal troubles are also public issues of society if we use the sociological imagination.

To fully understand our life means understanding how society has changed and the opportunities and threats to health that arise as a consequence. It means understanding that our personal agency, the freedom to act, operates within particular social structures that constrain action as well as providing enablements. So, what constrains our action, what enables us to take control of our lives?

Understanding obesity using the sociological imagination links the personal trouble of weight gain with the public issue of whole population shifts in BMI within the context of the obesogenic environment. A fuller understanding of ‘fatness’ goes beyond overly simplistic calculations of calories in = calories out type equations, and simplistic exhortations to “eat less move more”.

Implications:

Health and illness is to be thought as arising from social structure as well as, if not more than, biology. The knowledge that diabetes results not just from the individual’s choice of diet, but also from the social environment, should indicate a  public health and socio-political role. Health education is not just an individually focused issue, based on a biomedical understanding. Health itself has social origins. The concept of an ‘obesogenic environment’ suggests just that.

Therefore strategies that will assist people to move towards health must take into account the social and political context in which they live. Society has to change as much as the individual. Individualised models for change that ignore this will have less chance of success.

Understanding that illness, although at first may seem self-inflicted and out of free will, may result from the social milieu of the individual.  Victim blaming of the unpopular patient, the obese, the self-harmer, the drug addict, the alcoholic, is not only poor practice but is theoretically myopic. That is to say it does not understand the wider determinants of health. This realisation should change the language around health into a more open, less judgemental stance towards the people. For example, the label alcoholic implies the trouble lies within the individual when the roots may also be social.

To summarise: 

  • Health and Illness both derive from socially structured human agency, societal as well as biology.
  • The patterns, experience and causes of health and illness has to be understood in the context of history and culture.
  • The meanings that people attach to health and illness not only are built by social structure but go towards creating social structures.
  • Professionals need to acknowledge the complexity of health and illness and adopt a more open, non judgmental viewpoint.
  • There is a social/political and public health role.
  • Models for change have to go beyond individualised biomedical understandings of health and illness, realising that ‘education’ is not a universal panacea.

 

Benny Goodman      September 2017

 

Public Health and Health Inequalities: why is progress so slow?

Public Health and Health Inequalities: why is progress so slow?

 

This is one question contained in the 2009 report: Learning Lessons from the past: Shaping a Different Future written by the Marmot Review Working Committee 3 – Cross-cutting sub group report. (November 2009).  Hunter D, Popay J, Tannahill C, Whitehead M and Elson T.

The Marmot Review was published in the following year 2010. ‘Fair Society Healthy Lives’ described a mass of data on inequalities in health. A key concept was the ‘social gradient’ which suggests that one’s social position indicates one’s health outcomes at every point on the scale of socio economic status. It thus affects everyone.

The Social Gradient

http://www.who.int/social_determinants/thecommission/finalreport/key_concepts/en/

 

Hunter et al’s (2009) paper considered sources of evidence for ‘Fair Society’ and asked why better progress has not been made to reduce health inequalities and to suggest clear messages about the way forward.

 

  1. Why has better progress not been made? 4 key issues:

 

  • Delivery Mechanisms
  • Lifestyle Drift
  • Government handling of policy
  • Power, Knowledge and Influence.

 

1a. Delivery Mechanisms

 

  1. Delivery of public services and aspects of change has been based on a certain approach. This is the ‘rational linear change model’ which is both reductionist and mechanistic.
  2. This approach is also been driven from the centre.

 

The rational linear change model, is a process for making logically sound decisions. This multi-step approach aims to be logical and follow the orderly linear path from problem identification through to solution:  Problem: obesity. Cause: overeating. Solution: eat less, move more.

Reductionism means that the whole problem is broken down into reducible parts. Obesity can be broken down into its various elements and we can reduce it to a problem of over eating based on the simplistic notion of ‘calories in must equal energy expenditure’.

Mechanistic refers to the idea that one part of a mechanical system is easily affected in a ‘cause-affect’ way by another. This tinkering with a part of the system will produce observable and predictable results. So tinkering with the ‘calories in’ part of the mechanical system should produce weight loss outcomes:  ‘Eat less = lose weight’.

The centre includes central government departments such as the Department of Health. The tendency is to impose policy onto the NHS and front line staff. So an example of central policy is ‘Change 4 life’ or ‘Make every contact count’

1b. Failure of this approach to reduce health inequalities:

The Foresight Report (2007) on obesity identified the ‘obesogenic environment’. Therefore simple solutions (reductionist and mechanistic) such as targeting obese individuals with messages about eating less and moving more is only a small part of the solution. Foresight suggests there is no simple or single solution that works in a cause-effect way. ‘Change 4 life’ which focuses on individual lifestyle changes and behaviour changes will not be enough. This fails to engage with Foresight’s ‘whole systems approach’. Obesity has to be seen as a result of an interrelationship of factors (e.g. power relationships, poverty, employment). If responses are too narrow, focusing on individual lifestyle, the outcome will be failure.

The Economist Intelligence Unit published ‘Confronting Obesity in Europe. Taking action to change the default setting.’ (2015). It outlines the failures of such approaches. It accepts lifestyle and behaviour change programmes ‘are crucial’ but also frames obesity as a medical condition, note, not a socio-political one.  It also suggests that no European country has a comprehensive strategy for dealing with obesity. It quotes Zoe Griffith (of Weight Watchers):

“Education in schools , availability of healthy eating and restriction on marketing to children will go a long way towards resetting our society, but what they are completely ignoring is the majority of the population who are overweight and obese need treatment. It’s a very complex political and policy making environment”.

For current UK and Ireland trends see Public Health England data here.

Are Nurses who focus only on lifestyle and behaviour change with their patients, and who do not critique this approach, and who are also unable to be critically reflexive about their own weight gain, part of the problem and not the solution? This brings us to ‘Lifestyle Drift’ approaches:


 

2 Lifestyle Drift

This is the tendency for policy initiatives, for example Foresight, to recognise the need to take action on the social determinants of health (upstream approaches) but which as they get implemented drift downstream to focus on individual lifestyle factors. The Economist Intelligence Unit report illustrates the complexity of inter related factors. It also then asserts that lifestyle and behaviour change are ‘crucial’ and then frames obesity also as medical condition, thereby medicalising a social and political issue in an overly reductionist manner. It acknowledges the complexity but drifts towards medical treatment, as well as lifestyle change. However it does acknowledge the need for creating an environment that ‘deters obesity’ within a comprehensive strategy that involves transport, food, agriculture and education.

Lifestyle drift tends to move policy implementation away from measures that address the social gradient concept to measures that target the most disadvantaged groups in an attempt to deal with issues such as smoking habits, food choices and exercise levels. As nurses work with individuals and families it is easy to see how lifestyle and behaviour change tools are attractive in their attempts to ‘make every contact count’. Taking action on the social determinants of health is more of a challenge for many clinically based nurses who work in secondary and primary care. This is because nurses often don’t have either conceptual tools of analysis or control over social and economic factors such as housing. That being said, their understanding of their own weight issues would also be far too narrow if based intellectually on a lifestyle and behaviour change approach.

In ‘Lethal but Legal’ Freudenberg (2014) argues that the most important and modifiable cause of health inequalities is the “triumph of a political and economic system that promotes consumption at the expense of health” (p viii). To address health inequalities requires “taking on the world’s most powerful corporations and their allies”. Similarly, Stuckler and Basu (2013) point to Government policy, specifically austerity, as a danger to public health. A question for nurses is to what extent do we recognise that it is the actions of powerful actors that shape the social and economic conditions that result in the social gradient? Lifestyle approaches do nothing at all to address this aspect.

Hunter et al then discuss government handling of policy to explore more reasons for poor progress. Nurses will have a marginal interest in this aspect at best, beyond noting that failures of outcome include the internal processes in and between government departments. Therefore we will move on to their fourth issue.

 

  1. Power, knowledge and influence.

 

There is a causal relationship between inequalities in health and the social, material, political and cultural inequalities of the social determinants of health. Scambler’s health assets approach argues that material health assets are paramount in determining health outcomes. His ‘Greedy Bastards Hypothesis’ asserts that health inequalities in Britain are first and foremost an unintended consequence of the ‘strategic’ behaviours at the core of the country’s capitalist-executive and power elite. This is where health gets political. The strategic behaviours include getting governments to reduce state regulation, tax, control, ownership and provision for public services in order to facilitate the transition to corporate ownership, provision and control of public goods such as health and education. These corporations include Mitie, Serco, GE, Virgin and Capita. They are currently negotiating the Transatlantic Trade and Investment partnership (TTIP) between the US and the EU in order to make it easier to engage in business across the Atlantic. The TTIP will also allow corporations to sue national governments if they try to block renationalisation of health services, or if they engage in environmental or social regulations that is perceived to hurt business.

Scambler argues that the ‘capitalist class executive’ (CCE) are a core ‘cabal’ of financiers, CEOs and Directors of large and largely transnational companies, and rentiers. This ‘cabal’ has come to exercise a dominating influence over the state’s political elite including those in government. Quoting David Landes, Scambler suggests:

“men of wealth buy men of power” who then enact state policy which supports their activities and interests.

 

An example is Sir Philip Green’s handling of the BHS sale and the resulting shortfall in worker’s pension funds. It is argued that both Green and the new owner ran BHS for their own ends with little attention paid to the affect on 22,000 people working on relatively low incomes who now face a drop in pension income.

Evidence that corporate activities impacts on political decision making is provided by the delays to air pollution standards, Euro 6 (Archer, 2015; Neslen, 2015).  Volkswagen’s use of software to cheat emissions testing in the United States (Topham, 2015) indicates the lengths corporates will go to avoid externality costs resulting in the externality of, for example, increased air pollution.

Hunter et al argue that genuine redistribution of power and resources are required to address health inequalities. This reflects the WHO’s definition of the social determinants of health. They argue that policies aimed at wealth creation result in inequalities in social status and health, the latter is the price to be paid for wealth creation. This is commonly seen in justifications that argue that health, education and social security can only be paid for if the UK economy grows. Health inequalities that result from wider inequalities, and in keeping with lifestyle drift responses, are seen as the result of individual failure and behaviours, what Sandra Carlisle refers to as the ‘moral underclass thesis’ for health inequalities. This is allowed to occur because:

  1. The UK is a class divided society
  2. Behavioural Explanations support the idea of class division
  3. Public spaces for debate have declined, this contributes to the lack of a shared narrative and collective action. It allows the demonization of the working class via ‘Chav’ tropes.
  4. Political action has not allowed public engagement in decision making sufficiently to address the balance of power.

 

Conclusions:

 

To address health inequalities there is a need to consider:

 

  • Health Inequalities are a ‘wicked problem’.
  • Alternatives to the market model.
  • Social movements for change.
  • Current economic and political circumstances.

 

Wicked problems are such that there are no easy quick solutions, we need to understand that such issues as obesity result from a complex interplay of systems that is not always amenable to simple analyses and interventions. Telling people to eat better and move more clearly does not work.

Using ‘the market’ to address health is inadequate. People do not respond to price signals in the rational way that market theory expects, markets also rely on a balance of information between parties for equity to prevail and markets often ignore power imbalances and the rigging of such markets. The market in food and exercise regimes for example is skewed towards vested interests and the profit margin. Companies claim that in a market it is up to the consumer to make choices thus providing market information. The theory is that if we all shun sugar based foodstuffs the market would reflect those choices and companies would change business practices to suit.

There may be a need for social movements ‘from below’ to change powerful vested interests who profit from current economic structures and who also focus on the extremes of health (the obese rather than the overweight) for interventions. People are ‘free’ to make their own societies but not in the circumstances of their own choosing. Individualised responses cannot address those wider determinants of health.

The politics of ‘personal responsibility for health’ in the context of economic structures in which it is said “there is no money” for health and social services because the public debt has to be reduced requires challenging. For three decades a ‘hands off neoliberal approach’ to all social and political issues has been argued as the only approach. Public services have been privatised and marketised as if this is the only way to provide services.

 

Hunter et al conclude by arguing:

  • We need to debate redistribution and the type of society we wish to live in.
  • We need sustained resistance to lifestyle drift.
  • We need to resist silo based working.
  • We need to resist policy aimed only at ‘low lying fruit’ – the easy wins.

“the only way to achieve lasting reductions in inequality is to address society’s imbalances with regard to power, income, social support and knowledge…implement upstream policy interventions….supported by downstream interventions. ” (Priority Public Health Conditions Task group 8)

 

Poverty Privilege and Health

In two of the richest nations ever to have existed on planet earth we have a separation which allows affluent whites to exist in a bubble of privilege; a bubble of privilege which survives the shooting of police, deindustrialisation, poverty, precarity and the social gradient in health. Privilege understands and sees how radical losers exploit poverty and exclusion, but does not want to address social and economic structures; privilege understands that pain and anger can be turned both inward and outward but looks for solutions in the individual and ‘security’; privilege sees the transmission of poverty and exclusion only in the personal agency of the poor themselves.

Washington Heights is a suburb of the most segregated city in America. Charles lives in a part of Milwaukee where the residents are 99% white, yet a few blocks up are black neighbourhoods where shops are boarded up, many houses have repossession notices on their front doors, and the air is one of decay and poverty. The separation of black and white in Milwaukee is replicated in big cities right across the US, and separation breeds a lack of empathy.”

“Local authorities which report the highest rates of people facing severe and multiple disadvantage are mainly in the North of England, seaside towns and certain central London boroughs”

“Women who live in the least deprived parts of Kensington & Chelsea can expect almost a quarter of a century more of good health than their female counterparts in the most deprived part of the borough. For females at birth, the number of years an individual could expect to live in good health based on current rates – known as healthy life expectancy – differed by an average of 24.6 years between the most and least deprived parts of the borough” (ONS, 2015)

…and yet politicians like to focus on a ‘moral underclass’, blaming them for their behaviour that causes poverty. Drink and drugs are key factors in this regard:

“Ian Duncan Smith, Secretary of State for Work and Pensions, shocked readers of the Daily Mail with: ‘Addicts and alcoholics cost us £10billion a year, says Duncan Smith: Blitz launched to help people with drink drug problems find work’ “. (Glen Bramley LSE Blog)

There is a very old debate about whether poor people owe their circumstances to structural economic factors or to moral/behavioural failings. Sandra Carlisle in 2001 argued that there are ‘contested explanations, shifting discourses and ambiguous policies’  for health inequalities: there is the ‘Moral Underclass’ discourse, the ‘Social Integrationist’ Discourse and the ‘Redistrubutive’ discourse. Each has its own explanation as to why there are inequalities and then what to do about them.

Since Sandra Carlisle wrote her paper, there has been a a good deal of evidence to suggest that structural/economic forces are a major factor in people’s health and illness. There is some evidence also of ‘transmitted poverty‘ due to adverse childhood experiences. The misuse of Alcohol and Illegal substances (they are all drugs) are of course correlated:

“There is a huge overlap between the offender, substance misusing and homeless populations. For example, two thirds of people using homeless services are also either in the criminal justice system or in drug treatment in the same year”.

Many people faced with adverse social situations learn to cope, or they become fatalistic,  or they cling together in supportive communities or they become activists fighting for social justice.  Some self harm, some drink to excess, some go to University and become doctors or lawyers or politicians.  They exercise their personal agency and succeed or fail within structurally determined circumstances. They succeed, despite not because of, the activities and ideology of the privileged. A few of the successful however, then refuse to provide more ladders while shouting “I did it so can you”.

The lack of empathy, the total separation of lifeworlds, arises partly from moral intuitions that both blinds many politicians and commentators to alternative explanations pf poverty and binds them together in a bubble of privilege that prevents them from analysing the evidence. As we all do, they engage in post hoc rationalisations – in their case that that the poor are a moral underclass who are less intelligent, lazy, and hard working than the successful – to explain and justify their own positions.  This is almost a moral imperative, because not to blame the poor opens one up to the need to justify or critique the structural and economic privileges one has unequal access to. Placing the focus on the work, drinking and drug taking habits of a ‘moral underclass’ provides one with a sense of superiority and entitlement so much on show in both US and UK politics. No doubt the same occurs in Russia and China. To acknowledge that there are structural and economic conditions, for example the public school system or the service sector low wage economies,  or the inverse care law, opens up the middle class to accusations of champagne socialism.

This is a common tactic to deflect the argument away from an examination of causes to one of ‘ad hominem’.  Another tactic is to argue that the best way to address structural and economic factors is more of the same economic policies that have held sway especially in the US and UK. Indeed on a global scale the numbers of people living in absolute poverty is decreasing. Inequality is also decreasing with in the UK (gini coefficient). However these two factors are not the only issue.  Both the UK and the US are rich and other measures of inequality have increased, see for example the use of the Palma ratio. It matters greatly for very poor people to get incomes, and mortality rates, enjoyed by the poor in the UK and the US, but that is not enough as the social, health and political problems in both countries testify.

Privilege looks around and is satisfied knowing that the ‘have nots’ only have themselves to blame. They reach for the moral underclass theory and publish it relentlessly in their newspapers and commentary. They also have the wealth and political power to ensure this ideology is accepted by the poor themselves. However, many do not. In this context:

The losers get sick.

The losers get poor.

The losers get defeated.

The losers get mad.

The losers get even.

‘Many professions take losers as the object of their studies and as the basis for their existence. Social psychologists, social workers, nurses, doctors, social policy experts, criminologists, therapists and others who do not count themselves among the losers would be out of work without them. But with the best will in the world, their clients remains obscure to them: their empathy knows clearly-defined professional bounds’ (Enzensberger 2005). Enzensberger (2005) goes on to argue:

‘one thing is certain: the way humanity has organized itself – “capitalism”, “competition”, “empire”, “globalisation” – not only does the number of losers increase every day, but as in any large group, fragmentation soon sets in. In a chaotic, unfathomable process, the cohorts of the inferior, the defeated, the victims separate out. The loser may accept his fate and resign himself; the victim may demand satisfaction; the defeated may begin preparing for the next round. But the radical loser isolates himself, becomes invisible, guards his delusion, saves his energy, and waits for his hour to come’.

Shoots a Policeman, drives a truck through a crowd, blows himself up in an airport…..all the while privilege looks on in dumb uncomprehending horror calling for more security and economic crackdowns on the moral underclass upon whom the often middle class radical loser preys.

The More Beautiful World Our Hearts Know is Possible. Part 2.

The More Beautiful World Our Hearts Know is Possible.  Part 2. 

 

Part 1 discussed Charles Eisenstein’s outline of what he called the ‘old story’ of the world, at times called the ‘Story of Separation’. This was traced to its origins in western thought evolving into a ‘mechanistic’ view of life. I suggested that although nurse education understands concepts such a holism, actual adult nursing practice may still be based on the ‘old story’ which includes biomedical reductionism within a neoliberal discourse of ‘efficiency, economy and effectiveness’.

May 12th is ‘International Nurses Day’ and is being celebrated on twitter. For an, albeit self-selected, sample of nurses, and what they value, the tweets may present a particular view of what nursing is about. As such it is ‘espoused theory’, i.e. it is what we say we value and do. Following the #IND2016 reveals the thread and expressed values. It cannot however provide much of a clue as to the personal world views of nurses, their ‘epistemologies’, their ‘ways of knowing’ (empirical?) or their ‘ontologies’, ‘the meaning of existence or being’  (duality?).

An epistemology is how you think knowledge can be attained, it is about the nature, source and limits of knowledge, for example through sensory experience (empiricism). A biomedical epistemology bases its knowledge on physiology and anatomy, what can be measured and predicted according to laws of biological science. The subjective experience of illness cannot be taken as ‘proper knowledge’ because it cannot be seen, measured or is open to scientific experimentation or enquiry. The epistemology underpinning many alternative therapies accepts knowledge from theories of chakra, or theories such as ‘like cures like’ and argues that this knowledge is just as valid as knowledge derived from scientific randomised controlled trials favoured by biomedicine.

 

Ontology is the philosophical enquiry into the nature of being, becoming, existence and reality. A dualist ontology considers that there is a separation between the material existence of the human body and the external material world. It accepts that that mind and matter exist separately. Biomedicine adopts this understanding of the human body, that indeed the individual human body is a separate unit of existence from other human bodies, and indeed is separate from the whole of material existence. Therefore what happens to the individual affects only the individual, and what the individual does affects only their sphere of influence.

 

Student nurse education will be based on both these assumptions in the background. All of the work learning for example A and P and pharmacology are grounded in this world view. This holds for the majority of clinical skills learning. This holds true more for adult nursing than mental health and learning disabilities:

 

“Over the past few decades learning disability and mental health nurses…(are)… developing rapprochement with service users and a commitment to social models of care. In mental health care this can be seen in the development of recovery focussed care, while in learning disability Wolfensberger’s (1972) normalisation theory has had an equally radical impact. While adult nursing has also changed a great deal in the same time period, it has not undergone the seismic shifts in philosophy and approach to care that have taken place in these two disciplines. For very good reason, adult nursing remains committed to a biomedical vision of illness which, while cognisant of the importance of a holism, is tied to a physical approach to care.”  (Ion and Lauder 2015).

 

The context in which adult nurses work, and the nature of illness experienced by their patients, means that understanding health from the ‘new story’ view is perhaps idealistic for the majority of adult nurses.

The above descriptions of empiricist and dualist epistemology and ontology is what Eisenstein calls the ‘old story’. Thus, a brief outline of Eisenstein’s view of the ‘new story’ might provide a basis for some critical reflexivity. He variously calls it the ‘Story of Interbeing’, the ‘Age of Reunion’, the ‘Ecological Age’ or the ‘World of the Gift’.  Wendell Berry calls it the ‘world of love’ or ‘health as membership’.

This resonates with David Loy’s (1988) comment:

 

 “In this century it has become clear that the fundamental social problem is now the relationship between humankind as a whole and our global environment” (David Loy 1988 p 302).

 

Loy contrasts Eastern non dualist philosophical traditions, with mainly Western dualism in that:

 “….there is no distinction between “internal” (mental) and “external” (physical), which means that trees and rocks and clouds, if they are not juxtaposed in memory with the “I” concept, will be experienced to be as much “my” mind as thought and feelings” (p140).

 

This then is a non-dualist viewpoint in which ‘us’ includes the biosphere; we are indivisible as human beings from all life forms and all matter.

 

The principles of Eisenstein’s ‘new story’ are (p15):

  1. That my being partakes of your being and that of all beings. Our very existence is relational going beyond interdependence.
  2. What we do to another, we do to ourselves.
  3. Each of us has a unique and necessary gift to give to the world.
  4. The purpose of life is to express our gifts.
  5. That every act is significant and has an effect on the cosmos.
  6. We are fundamentally unseparated from each other, from all beings, and from the universe.
  7. Every person we encounter and every experience we have mirrors something in ourselves.
  8. Humanity is meant to join fully the tribe of all life on earth, offering our uniquely human gifts towards the well-being and development of the whole.
  9. Purpose, consciousness, and intelligence are innate properties of matter and the universe.

This view may be more applicable to one’s personal view than to clinical practice. It might be interesting to think what clinical practice might look like if we took these precepts seriously? The current design of hospitals and clinics, the clinical pathways we develop and the sort of practitioner we educate is based on the ‘old story’ of biomedicine, so we know what that looks like. It is our current world.  Could it be possible to redesign and to rethink?

This is philosophy, but Eisenstein argues this fits with what physics tells us about the world, it is more than ‘new age’ assertion and hope. There is a continuing divide however between the new paradigms of physics and biology and the Newtonian mechanistic world view of everyday experience. The one is the espoused theory – what scientists and philosophers say is so, and practical action – what we actually do and experience as adult nurses.

The issue goes beyond what clinical practice looks like and where it takes place. The ‘old story’ underpins our ecological, social and economic crises because it narrows the definition of what it is to be human, what reality is and thus what the possibilities are.

Yagelski (2011) calls this ‘the problem of the self’:

“My argument here is that the prevailing Western sense of the self as an autonomous, thinking being that exists separately from the natural or physical world is really at the heart of the life-threatening environmental problems we face”.

Student nurses in the Adult field in the UK are schooled, and experience, the ‘autonomous, thinking being’ separate from the natural, physical and social world. The political world is torn between Margaret Thatcher’s ‘no such thing as society, only individuals’ and a more social(ist) democracy. To date Thatcher’s view prevails as a core element of neoliberalism.

Adult nurses go to work within a mechanistic, empirical, patriarchal, separate, reductionist and biomedical context. This is a world in which the cause-effect relationship of the RCT is the gold standard for evidence. They will have a clear sense of boundaries between themselves and their patients and with other health professionals. The work context is similarly managed in a fragmentary way, units of work need to be measured and evaluated, processes clarified, evidence to be checked. Wendell Berry calls this the ‘world of efficiency’.

He also refers to the ‘world of love’, a world which Eisenstein might recognise as ‘Interbeing’.

However, this is a view that hospitals and industrialised medicine struggle to understand and thus cannot ‘heal’ or make ‘whole’. Berry accepts that the hospital does well at surgery and other procedures, treating the body and its parts as separate things.

 

Healing, however, meaning reconnecting and making whole, is alien to many medical practices. For example, any place of healing would emphasise and prioritise such things as rest and food. Whereas a hospital treats a body as a machine that needs fixing and that the rest it needs is a low priority. Both sleep and nutrition in acute hospitals continue to be topics addressed in the literature as not always delivered in the best way possible. The very design of hospitals seem antithetical to both.

 

Berry argues that rest, food and ecological health ought to be the basic principles of the art and science of healing, but currently healing is based on other principles: biomedicine technology and drugs. Berry criticises biomedical practices for making only tenuous links between healing, rest and food and no link at all between health and the soil:

 

Industrial medicine is as little interested in ecological health as is industrial agriculture” (p98).

 

This sentence makes no sense unless health is defined within a non-dualist, non-reductive ontology.

 

This disconnect between healing, health and medicine is illustrated by Berry by describing the experience of his brother’s heart attack. The debt to the hospital is acknowledged, as John his brother underwent a Coronary Artery Bypass graph. In the hospital the ‘world of love’ confronts the ‘world of efficiency’ – i.e. medical specialisation, machinery and procedures.

 

John came from the ‘world of love’ of family, friends, neighbours which the hospital struggled to deal with. This world of love seeks for full membership, it seeks to be joined. However the world of efficiency ignores this love as it must ‘reduce experience to computation, particularity to abstraction and mystery to a small comprehensibility’. In other words any experience that cannot be objectively measured and calculated is devalued and takes second place to the ‘real’ work of diagnosis, intervention and evaluation.  Hence the focus on vital signs, NEWS, blood gas analysis, blood tests (FBCs, U and Es), ECGs, urine output, X-rays and CT scans; the particularity of a patient’s pulse is abstracted to concepts such as hypovolaemia; the particularity of a real person is abstracted into a set pf physiological parameters transformed into documentation replete with risk scores and reduced into medical categories; the mystery of the pale, clammy patient, expressing chest pain has to be comprehended as myocardial infarction (or other diagnostic category that gives meaning).

 

Efficiency must ally itself to machinery – John was in the intensive care unit – to standardise, to provide numbers to predict and control. The efficient nurse will use all the tools that biomedical science gives to provide the best physical care. The effective nurse will use the appropriate biomedical tools and interventions which are evidenced based; the economic nurse will do so with the minimum of cost.

 

Love however cannot be standardised, is not a graph, a chart, anatomy, an explanation or a law:

 

“The world of love includes death, suffers it, and triumph over it. The world of efficiency is defeated by death; at death all its instruments and procedures stop. The world of love continues and of this grief is the proof” (p105).

 

The professional ‘field’ of adult acute care excludes the ‘amateur’, excludes the world of love. Descriptions from the professionals to the family that procedures were ‘normal’ failed to acknowledge that nothing about this was normal. Normality for them was biomedically defined, was what they have experienced with other patients. Lying in a hospital bed is pretty far from normal for everyone else.

 

The worlds of love and efficiency divided experience, however people can cross between. The amateur may not be able to cross into the world of efficiency. The machines and data are ‘a foreign land’, but the professional can cross into the world of love:

 

“During John’s stay…there were many moments in which doctors and nurses – especially nurses! – allowed or caused the professional relationship to become a meeting between two human beings” (p108).

 

Berry described on such moment. John’s wife Carol was waiting for news of the bypass operation, and as a nurse also knew the seriousness of the situation. Two nurses came to tell Carol that the operation had been a success and that during the procedure a balloon pump had been inserted into the aorta, a possibility that had never been mentioned.

 

Carol being unprepared for this news was disappointed and upset. The two nurses tried to reassure her by repeating what they had just said (professional and within the world of efficiency). Then there was a long moment when they just looked at Carol.

 

One of them then said “Do you need a hug?” Carol said “Yes”.

 

This brings us to a starting place, a starting place for healing and a crossing over into the world of love.

 

Many nurses today will understand this crossing over, many will intuit that the world of love is part of healing, of health as wholeness even while they work on the world of biomedical efficiency. This is a corrective to the isolationist, reductive and machine like process of ‘nursing’ care in some hospitals and care homes. However, at times we struggle to provide this ‘world of love’ as the Ombudsman report (2016) into the hospital discharge of older people testifies.

 

Eisenstein asks us to consider that separation causes distress and provides the wrong solutions. If we really believed and felt that the old person sitting alone in bedroom was us, would we want to change things?

I accept that I can’t do it. I can’t heal those around me. I’m stuck in the transition between the world of love and the world of efficiency. I am not able or willing to pay the heavy price to close the gap by myself.  I can make a difference, though, to some and Eisenstein argues that little differences can add up. What is my gift to the world? Having read Eisenstein , I have to admit it is not a question I’ve ever addressed. My sense of self is individual, is separate, is ‘dualist’ and yet I know it could be different? The new story is a vision of where I could be, it is not where I am.

I don’t think this is matter for individuals to provide an individual response to such issues as loneliness. It would be a ‘good thing’ of course if isolated lonely old people had visitors, and that the visitors themselves would benefit from that. However, that is the ‘old story’s’ solution. Many individuals do not have the time, energy, resources emotional and physical, the geography or the history to close the gaps. That is because our total system of care mirrors the social, economic and political systems that emphasise efficiency, effectiveness and economy and the sovereign individual. That is why our culture is increasingly turning to individual responsibility for health, education and welfare. Health and social care is framed within austerity budgetary constraints, we cannot think about anything other than the financial costs.

This means we cannot imagine or vision “a more beautiful world our hearts know is possible”.

 

 

 

 

How responsible am I for my health 2

How responsible am I for my health?

 

The answer to that question from the dominant discourse is an overwhelming “very”.

This response sits alongside more scholarly understandings of the social determinants of health.  This ‘upstream’ understanding is open to ‘Lifestyle Drift’ , ‘downstream’, responses to health. Lifestyle Drift is:

“the tendency for policy to start off recognizing the need for action on upstream social determinants of health inequalities only to drift downstream to focus largely on individual lifestyle factors” (Popay et al 2010)

McKenzie et al (2016) argue:

“Although policy documents may state that the causes of poor health or inequalities in health are to do with poverty and deprivation, the interventions which actually operate on the ground focus much less (if at all) on changing people’s material circumstances and rather more on trying to change behaviours (which are in fact heavily shaped by material circumstances)”.

Nurses might understand the concept of the social gradient in health inequalities but drift into advocating lifestyle changes for the individual, centring around smoking, diet, and exercise messages.

So why is this happening? Why resort to lifestyle approaches to health when we know health is largely socially and politically determined?

 

One answer is that lifestyle answers fit within the neoliberal social imaginary which individualises health and social problems and seeks market solutions to those problems. Neoliberalism is a doctrine well known to many scholars and academics but is hardly mentioned in popular discourse.  To understand responses to health inequalities and poverty , we need to understand the tenets of neoliberalism underpinning much of current thinking:

 

  • Neoliberalism sees competition as the defining characteristic of human relations. Therefore competition between service providers should be introduced into the NHS.
  • It redefines citizens as consumers, whose democratic choices are best exercised by buying and selling, a process that rewards merit and punishes inefficiency. So patients can and should choose between hospitals and GP practices as consumers of health care using their purchasing power (not yet realised in the NHS). This way, poor service providers should go out of business.
  • It maintains that “the market” delivers benefits that could never be achieved by planning. Therefore NHS = bad, US private health insurance = good; BBC = bad,  SKY/Fox = good;  British Rail = bad, Great Western/Virgin = good; Royal Mail (state owned) = bad, Royal Mail (privately owned) = good.
  • Attempts to limit competition are treated as inimical to liberty. Thus socialised NHS service provision must be broken up to allow freedom in the market. The BBC must be sold off because it is unfair competition for Sky.
  • Tax and regulation should be minimised, thus the use of offshore tax havens, reduction in top rate of tax, mistrust of EU environmental standards and hatred of health and safety regulations.
  • Public services should be privatised. The Health and Social Care Act 2012 facilitates this, there may well be more to come for the NHS.
  • The organisation of labour and collective bargaining by trade unions are portrayed as market distortions, that impede the formation of a natural hierarchy of winners and losers. Unison, RCN, BMA etc, must have their power curtailed. The Junior doctors cannot be allowed to win or else it will be a victory for organised labour.
  • Inequality is recast as virtuous: a reward for utility and a generator of wealth, which trickles down to enrich everyone. Those at the bottom require incentives to better themselves, therefore benefits need cutting, those in the middle will benefit from wealth creation.
  • Efforts to create a more equal society are both counter-productive and morally corrosive. The market ensures that everyone gets what they deserve. The arguments from books such as ‘The Spirit Level’ are therefore irrelevant. If there is a social gradient in health then this is the natural outcome of people’s decisions and choices and any attempt to change this invokes  ‘moral hazard’ arguments; that is if people know they have a safety net (someone else takes the risk) they will not try to avoid poor choices.

(Monbiot 2016 The Zombie Doctrine)

 

 

 

Tory Rituals on poverty:

 

 

·         Blame the individual for their illness and poverty.

·         Benefits cause dependency , repeat this ad nauseam.

·         Deny any political responsibility for ill health, emphasise culture as causative.

·         Divide population into:  skivers v strivers, deserving v undeserving poor, low achievers v high achievers.

·         Deny the ‘social’ exists, there are only individuals

·         Privilege wealth through tax breaks and preferential treatment.

·         Deny one’s own privilege as a white affluent male.

 

 

These attitudes underpin the ideology of neoliberalism.

 

For a statement about what the Conservative Party should be about see:Direct Democracy – an agenda for a new model party’ (2005) especially the chapter on health:

 

 

“The problem with the NHS is not one of resources. Rather, it is that the system remains a centrally run, state monopoly, designed over half a century ago”.

 

 

 

All of this results in the politics of blame and shifting responsibility for health fully onto individuals.

If material health assets are paramount, poverty and our response to it is a foundation for understanding health in society. Poverty can be defined as 60% of the median income or using the ‘consensual method’  it is “enforced lack of necessities determined by public opinion”.

However, the UK government’s position is that poverty is not caused by lack of income. Based on Charles Murray’s idea of the ‘Culture of Poverty’, poverty is a result of individual deficits, as Kitty Jones writes:

“the poor have earned their position in society, the poor deserve to be poor because this is a reflection of their lack of qualities, poor character and level of abilities”.

Kitty Jones has written clearly on this issue in 3 blogs, which can be found here.

The alternative view, expressed in for example the ‘Greedy Bastards Hypothesis’ is that poverty, and health inequalities, is caused by the rich, often through unintended consequences of their actions but also through design. It results from structural socio economic conditions that neoliberal governments encourage: for example, low wages, withdrawal of benefit provision and the use of offshore tax regimes. Osborne’s ‘living wage’ is a cynical political manoeuvre designed to woo middling swing voters rather than to address structural economic issues such as under and unemployment , lack of investment in a green economy, deficits in the housing stock and affordability and a zero hours, self employed precarious job structure.

 

Nurses offering health advice, are not immune to this dominant discourse. It suffuses health advice on such sites as NHS choices and is supported by health campaigns which focus on changing individual habits. Action on social inequalities as root causes for ill health sits within specialised public health literature, for example ‘Fair Society,  Healthy Lives’, and unless nurses are exposed to an alternative perspective they will naturally draw upon dominant explanations for health inequalities. These are often either biologically/hereditarian explanations* or a ‘moral underclass discourse’ (Ruth Levitas) or a mix of the two. The politics of neoliberalism encourages the latter perspective.

 

 

Benny Goodman 2016

 

*See Chapter 4 in Psychology and Sociology in Nursing  Goodman 2015 for explanations.

Watch Richard Wilkinson discuss inequalities at a TED talk.

https://www.facebook.com/groups/Sociologyhealthnursing/

 

 

 

 

 

 

Choose your parents

Alejandro Nieto.

Bernal Heights. San Francisco.

What has the death of a young man, shot by four police officers in a park in California got to do with with understanding health outcomes in the United Kingdom?

Mary Sue and Miriam. Two women born at similar times whose grandparents came from the same small town in the United States. One will be going to an Ivy League University while the other struggles with drugs and hopelessness writing on her Facebook page ‘Love hurts, Trust is dangerous’.

What links them is that Alejandro and Mary Sue ‘chose the wrong parents’, while Miriam chose wisely, a Harvard professor for a grandfather (Robert Putnam), and University educated parents.

Their cases illustrate that health and well being is ‘structured but not determined’, that to truly understand their life chances we have to consider the transformations in society that impact on the choices made and opportunities open to individuals and their families.

Alejandro was born to Mexican immigrants who came to San Francisco in the 1970’s. His mother worked all her life while his father took on most of the child care duties. San Francisco has a history of immigrants from other parts of the US as well as from elsewhere. Being Hispanic in California is ‘normal’ but not to the white, male, educated tech engineers from Silicon Valley who have moved to the area en mass ushering in gentrification and myopia. Alejandro was described to the Police as probably ‘foreign’ who had a gun, his red jacket marking him out as a gang member. All of this was supposition and assumption. Alejandro had lived in Bernal Heights all of his life, the gun was a taser, carried because he worked as a security guard. His red jacket was a sports jacket, the colour of the local sports team the 49’ers. Those doing the describing were white tech engineers making assumptions about behaviour. Indeed, Alejandro was holding a taser, but he had just been harassed by a dog barking and jumping up at him to get at his chips. The dog owner was 40 feet away, distracted by a ‘jogger’s butt’ and unable to keep his dog under control.

The police arrived, and shot him, one unloading over 20 bullets and had to reload.

Alejandro, Mary Sue and Miriam live at a time when the United States is experiencing growing inequalities in wealth, segregation in its communities, family instability and a collapse of both good working class jobs now being followed by a squeeze on middle class opportunities. While the wealth of the 1% has increased based on their increased share of wealth being created – they are getting an even bigger slice of the pie, working class incomes have stagnated. Mary Sue’s grandfather used to have a decent income from a solidly working class job, now gone leaving ‘flexible’, low paid insecure work.

As economies restructure, as cities adapt to new social conditions, people experience changing social structures that enhance or diminish their chances. The white Ivy League tech engineers are likely to know only other white Ivy Leaguers, to come from Ivy League parents, went to the same schools and know only their own kind in a networked bubble of privilege, social myopia and self satisfying smugness. They don’t know the ‘other’ and can thus label a sports fan as a gang member with in this case lethal consequences.

Perhaps representing their views:

“I know people are frustrated about gentrification happening in the city, but the reality is, we live in a free market society. The wealthy working people have earned their right to live in the city. They went out, got an education, work hard, and earned it. I shouldn’t have to worry about being accosted. I shouldn’t have to see the pain, struggle, and despair of homeless people to and from my way to work every day.”

 

So ‘free market society’ justifies the breakdown of community, segregation, inequality, fear and mistrust. Wealth is ‘earned’ rather than a result of circumstances (right time, right family, right ethnicity, right gender, right neighbourhood, right education, right opportunities and often the inheritance of not only financial but social and cultural capital). Indeed, no one should have be be accosted, no one should see pain and struggle and despair, but don’t blame the victims of unjust social, political and economic systems. Don’t blame the dog for barking when someone’s kicked it.

Alejandro’s ‘personal trouble’ (being shot) is now a public issue. When only one young man is shot by police, we might consider the character of the man and look to him as an individual for reasons and solutions. When hundreds of young men are being shot by police this individual analysis is no longer useful, we must look to social structures, to link personal stories to this point in time in this particular society.

Miriam can look forward to a bright future, she experienced great parenting, great education backed up of course by well resourced material assets. Mary Sue, is a single parent with no education, self harm, a drug habit and abusive partners. Her child will very probably not go to Harvard. Alejandro made the mistake of being born Hispanic and thus a potential threat to the White denizens of a newly gentrified neighbourhood.

If you are struggling to apply this to the UK context, you don’t know the truth and you lack the ‘sociological imagination’.

Alejandro’s story is in Rebecca Solnit ‘Death by Gentrification’. Opinion. The Guardian. March 22nd 2016.
Mary Sue and Miriam’s story is in a talk by Robert Putnam to the RSA in London, March 2015, on ‘Inequality and the Opportunity Gap’. https://www.thersa.org/discover/videos/event-videos/2015/10/robert-putnam-on-inequality-and-opportunity/#

NHS Dissatisfaction levels are perhaps not yet high enough to embolden the political power elite to further uncouple NHS principles from actual delivery, but they might be going in the right direction.

How satisfied with the NHS are we? The British Social Attitudes Survey has been tracking satisfaction levels since 1983. In 2011 it reached the highest it had been (64%), much higher than the 39% recorded in 2001. In 2000 there was a large rise in funding and according to John Appleby (Kings’ Fund) the change upwards might reflect that extra funding. In 2010 the rate had hit 70%, while in 2015, 65% stated they were quite or very satisfied, with dissatisfaction at a low of 15%. Now, in 2016, dissatisfaction rates have hit a 23% ‘actively dissatisfied’.

 

For trends see the graph at:  http://www.bbc.co.uk/news/health-35527318)

 

 

So, should we read anything into these figures? The “NHS’ is a complex set of organisations and services, and is affected by such external factors such as social care. It is probably foolish to peg changes in attitudes to any one factor (such as funding or waiting times). The survey does provide some information as to why those who are dissatisfied say so:

 

The stand out reason is taking too long to see a GP (60%). Interestingly only less than 5% state ‘stories on TV or radio’. However, 6 reasons above that are also gained by reading the press, watching TV as well as being supplemented by actual experience of friends and family.

See reasons at http://www.bbc.co.uk/news/health-35527318)

 

The figures cannot be directly tracked to funding or political party. The background of the Health and Social Care Act 2012 has not on the face of it made a difference to people’s attitudes. The high rate of satisfaction in 2010 of 70% has dropped to around 60% since, while dissatisfaction has only just started to rise again from the 2011 level.

 

If you want to change the way the NHS is funded, this survey is still an issue. Too many people like it the way it is, “free at the point of delivery” is a possible reason. Social Care (means tested) ranks the lowest on these satisfaction scores and might indicate that funding is a real issue for people.

 

 

The context for this includes 4 assumptions held by governments over the past 25 years: Neena Modi in the Guardian writes:

 

  • Personal responsibility for health supersedes government responsibility.
  • Markets drive efficiency.
  • Universal healthcare is unaffordable.
  • Healthcare is a business.

 

For example, Christopher Smallwood wrote ‘Free at the point of use’ has had its day and argues for private health insurance.

 

Each one of these assumptions are questionable and draw upon a certain view of the role of the state vis a vis the private individual (neoliberalism). Alongside that there are profit making health care organisations looking for new business opportunities that the relatively closed NHS used to block. Graham Scambler’s ‘Greedy Bastards Hypothesis’ suggests that health inequalities are the unintended consequences of the actions of a core cabal of the ‘capitalist executive’ who, aided by the ‘political power elite’ engage in business activities aimed at capital accumulation which includes commercialisation of health services for profit. The Health and Social Care Act 2012 provided an opportunity for just such private sector involvement. A problem for the private sector is that much demand for services comes from an increasingly ageing population whose needs are difficult to make a profit from.

 

 

There are very real discussions to be had about the sort of health service we want and the principles that should underpin it. There is now increasing argument for a rolling back on its founding principles of universal access, comprehensive coverage, equity of service and free at the point of delivery all in the name of ‘affordability’ underpinned by an ideology that deplores public sector provision. Dissatisfaction levels are perhaps not yet high enough to embolden the political power elite to further uncouple NHS principles from actual delivery, but they might be going in the right direction.

 

 

 

For discussion on health services globally see:

 

  1. Which country has the best healthcare system?
  2. Britnall, M (2015) In Search of the Perfect Health System. Palgrave macmillan .

 

 

 

 

 

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